Inside Health

For Physician Assistant, Empathy Goes Two Ways

By ANTHONY RAMIREZ

Published: May 5, 2008

This is a story about health care that is not universal. There is a name attached: John C. Welton, from the Bronx, father of two and husband to Vivian.

Mr. Welton is a physician assistant. Because of his job and what he has lived through, Mr. Welton is unusually familiar with the wounds that flesh is heir to. He has therefore learned something important: to savor life, in his patients and in himself.

Now 60, he has survived polio. In 1953, he and two of his brothers contracted the virus on the same summer day at Orchard Beach in the Bronx. His brothers made a full recovery. Mr. Welton did not.

From the neck up, Mr. Welton looks like Santa Claus before his beard turned white. From the chest down, he is atrophied. He walks with crutches, his right leg bearing the weight of his 130-pound body.

Mr. Welton's spine is curved. His clothes hang on his 5-foot-6-inch frame. Metal braces thicken his legs. He does not wear a long white coat because it might tangle his crutches. Still, Mr. Welton's appearance is a professional advantage, he said. ''A lot of times when I come into the room and a patient sees me,'' he said, ''there's this feeling of, O.K., he's going to understand what I'm going through.''

Mr. Welton works the late shift at Montefiore Medical Center in the Bronx, where on quiet nights the only thing that can be heard in the corridor is the sucking sound from the rubber tips of Mr. Welton's crutches on the floor.

A physician assistant for 26 years, Mr. Welton works on what is known as the palliative care unit for patients with progressive, incurable illnesses, like terminal cancer. The unit has 15 beds. He takes patients' medical histories, prescribes their medication, checks their vital signs and declares time of death when their end comes. He started working at the palliative care unit last year.

Physician assistants, as some have tartly observed, do 80 percent of a doctor's job for 50 percent of the pay. (The annual salary averages about $82,000.) They are not legally entitled to be called doctor, although some patients do call Mr. Welton ''Doc.''

There are more than 68,000 such practitioners in the country, according to the Physician Assistant History Center, in Durham, N.C. The profession grew out of a desire to use the real-world experiences of combat medics returning from the Vietnam War.

As patients live longer and chronic illnesses grow more complex, health experts project a shortage of doctors and an even stronger demand for physician assistants. In 1980, Mr. Welton went through a two-year physician assistant course at Long Island University.

Physician assistants are supposed to work under the supervision of a physician. Dr. Rose Guilbe, 52, is one of the physicians who hired Mr. Welton, and she supervises him in the palliative care unit.

The physician assistant is ''the bedside provider,'' Dr. Guilbe said. What Mr. Welton in particular contributes is a rich experience of working with the seriously ill, Dr. Guilbe said.

Recently, Mr. Welton started the last of his week's three late-night shifts, which last 12 hours, as usual at 7 p.m.

The first hours are the busiest. Patients' visitors are allowed to stay until 8:30. Most patients are asleep by 10. If Mr. Welton has to visit a patient after those hours, it often signals trouble.

The first patient he looks in on is a gaunt 22-year-old man with advanced leukemia and little or no resistance to disease.

The next patient, an 88-year-old woman, is in distress. She has emphysema and advanced Alzheimer's disease. Mr. Welton checks on her frequently.

By the time patients have reached the palliative care unit, most are quiet, communicating in a whisper or a simple head movement. Mr. Welton has to assess whether a seeming look of fear is disorientation or a signal of pain.

Carrying out his work is not easy. To listen to a patient's heart, Mr. Welton steadies himself on crutches, then leans forward like a flamingo, his right hand aiming his stethoscope toward the patient's chest.

To check patients' information on his office computer, Mr. Welton must first plop his chin and chest on a surface in front of him, forming an inverted L. He then unlocks his leg braces and eases into a chair.

The hours pass. At 1:23 a.m., Mr. Welton takes two Tylenol tablets for arm and shoulder pain from using his crutches, and then a caffeine pill.

Hospitals used to frighten him. They still do, in his dreams. When he was a boy recovering from polio, a nurse would carry a pile of hot, wet blankets to wrap around his paralyzed legs, a common treatment for polio in the 1950s. When he dreams about that, he shudders. ''It's the smell of wet wool,'' he said.

Suddenly, at 4:35 a.m., he receives an urgent call from a nurse. An 82-year-old woman is having trouble breathing. She is frail, with a shock of white hair. Mr. Welton notices two words on her chart, ''paranoid schizophrenic.''

''I'm going to sit you up a little,'' Mr. Welton says loudly to the patient. ''When was the last time you took your pills?''

''Every day,'' she hisses.

''Having pain anywhere?'' Mr. Welton asks. She says nothing.

''Just trouble breathing?'' She nods.

Mr. Welton stares into her face. ''Can you tell me who the mayor of New York is?'' he asks. ''Leave me alone!'' she screams.

Minutes later, at 4:50 a.m., Mr. Welton is called to the bedside of a 53-year-old man with liver cancer who has vomited blood. The man's blood pressure cannot be detected, and his jaw is slack. Mr. Welton is worried.

At 4:53 a.m., he telephones the man's wife. ''Your husband has taken a turn for the worse,'' Mr. Welton says, ''and it is very likely he is going to die.'' She tells him that she is getting into her car.

But by the time Mr. Welton is briefing the incoming morning shift at 7:30 a.m., it is not the man with liver cancer who has died, but the 88-year-old woman with Alzheimer's. The man with cancer would die in the afternoon.

No one confronted by death every day can fail to ponder it in quiet moments. Mr. Welton is no exception. In 1993, he experienced muscle weakness that was diagnosed as post-polio syndrome, a progressive wasting disorder. So far, the syndrome has not affected Mr. Welton's ability to work. But polio damaged his diaphragm, and Mr. Welton has noticed problems recently with breathing and swallowing. He has started sipping rather than gulping, fearing he may choke. Mr. Welton describes it as ''an aspiration risk.''

He adds, ''It's nothing that's gotten in my way yet.''

PHOTO: John C. Welton, who had polio as a boy, cares for dying patients at Montefiore Medical Center.(PHOTOGRAPH BY MICHELLE V. AGINS/THE NEW YORK TIMES)